The Director of Nursing acknowledged the training gap during a federal inspection in December. He told inspectors that while floor nurses would provide "step-by-step instructions" for safe transfers and walking to residents with fall histories, no systematic training existed for certified nursing assistants who provide most direct care.
Orthostatic hypotension causes dizziness and fainting when people rise from sitting or lying positions. The condition is common among elderly residents and can lead to serious injuries from falls.
The facility admitted residents with documented fall histories that required specific safety protocols upon admission. Despite this, the DON confirmed that CNAs - who help residents with daily activities like getting out of bed and walking to bathrooms - had not received specialized instruction on recognizing or preventing falls related to the blood pressure condition.
The nursing director told inspectors that all residents were considered at risk for falls and that staff understood general fall prevention measures. However, he could not point to any formal training program that addressed the specific risks and prevention strategies for orthostatic hypotension.
The inspection found that while individualized fall prevention plans should have been implemented for residents with fall histories, the lack of targeted training for direct care staff created gaps in safety protocols. CNAs, who spend the most time with residents during transfers and mobility assistance, were expected to follow detailed instructions without formal education on the underlying medical condition causing fall risk.
Federal inspectors cited the facility for failing to ensure adequate staff preparation for preventing falls among vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale Greenwood Village from 2025-12-01 including all violations, facility responses, and corrective action plans.